Trait anxiety, symptom perceptions, and illness-related responses among women with breast cancer in remission during a tamoxifen clinical trial

The Unintended Consequences of Adverse Event Information on Medicines' Risks and Label Content

Patients and prescribers need to be aware of adverse drug events to minimize the risk of their occurrence and the severity with which they appear. However, numerous studies show that being informed about adverse events can increase the possibility of suffering from them. Patients tend to overestimate the likelihood of experiencing the adverse events included in the label, and this can contribute to worsening the negative expectations which are at the root of the nocebo effect. In fact, patients can become anxious after reading the undesirable effects section of the leaflet and, in addition to suffering from the nocebo effect, might not take a drug they could benefit from due to the fear of experiencing adverse events. In addition, patients' attention can focus towards non-specific symptoms of daily living that can be misattributed to the drug and included in the labelling. This article proposes a number of suggestions to reduce the abovementioned unintended effects associated with labelling, namely, an increased focus on the excess risk of experiencing adverse events rather than crude incidence, using attribute framing to help patients to better understand the risk of experiencing adverse events, dividing the undesirable effect section of the leaflet into subsections according to the level of evidence supporting causal relationships and, finally, restricting the addition of non-specific adverse events that are also symptoms of daily living to only those where there is enough evidence to show they have been caused by the drug. More studies on how to minimize the nocebo effect induced by adverse event information should be performed, and these should be done in collaboration with health authorities, to reach a shared consensus on how to better present adverse event information in the label.

Using the common sense model of self-regulation to understand the relationship between symptom reporting and trait negative affect

BACKGROUND/PURPOSE

Based on the Common Sense Model of Self-Regulation, we examined if the relationship of trait NA to physical symptom reporting was moderated by life events and illness representations.

METHODS

This relationship was examined using a cross-sectional dataset of 554 elderly adults.

RESULTS

A significant three-way interaction demonstrated that individuals who reported the greatest severity of physical symptoms were higher in trait NA, and reported more life events and a chronic illness history.

CONCLUSIONS

The results of this study are consistent with the hypothesis that individual high on trait NA who have a history of a chronic illness have illness representations with both disease specific physical symptoms and symptoms from other causes, such as emotional distress. This may complicate the care of medical conditions for these patients.

Cancer symptom awareness and barriers to medical help seeking in Scottish adolescents: a cross-sectional study

BACKGROUND

Initiatives to promote early diagnosis include raising public awareness of signs and symptoms of cancer and addressing barriers to seeking medical help about cancer. Awareness of signs and symptoms of cancer and emotional barriers, such as fear, worry, and embarrassment, strongly influence help seeking behaviour. Whether anxiety influences seeking medical help about cancer is not known. The purpose of this study about adolescents was to examine: 1) the relationship between contextual factors and awareness of signs and symptoms of cancer and barriers (including emotional barriers) to seeking medical help, and 2) associations between anxiety and endorsed barriers to seeking medical help. Interpretation of data is informed by the common sense model of the self-regulation of health and illness.

METHODS

A cross-sectional study of 2,173 Scottish adolescents (age 12/13 years) using the Cancer Awareness Measure. Socio-demographic questions were also included. Descriptive statistics were calculated and two Poisson regression models were built to determine independent predictors of: 1) the number of cancer warning signs recognized, and; 2) number of barriers to help seeking endorsed.

RESULTS

Analysis identified that knowing someone with cancer was a significant independent predictor of recognising more cancer warning signs whereas Black and Minority Ethnic status was a significant independent predictor of recognising fewer cancer warning signs. Emotional barriers were the most commonly endorsed, followed by family, service and practical barriers. Over two thirds of adolescents were 'worried about what the doctor would find' and over half were 'scared'. Higher anxiety scores, knowing more cancer warning signs and female gender were significant independent predictors of barriers to help seeking.

CONCLUSION

Improving cancer awareness and help seeking behaviour during adolescence may contribute to early presentation. Contextual factors (for example, ethnicity, gender, knowing someone with cancer), and emotional dimensions (for example, anxiety, fear, worry) are critical components in help seeking behaviours. The role of emotional factors indicates that public health campaigns focused on awareness and help seeking may benefit from having a more emotional focus, for example, including references to feelings, such as, fears and worries.

Trait anxiety predicts disease-specific health status in early-stage breast cancer patients

Purpose

The objectives of this study were to examine the differences in health status (HS) of women with breast cancer (BC) at different moments in time, and between women scoring high and not high on trait anxiety, and to identify possible predictors of HS 6 and 12 months after surgery.

Methods

Patients (N = 223) completed a trait anxiety questionnaire before diagnosis. Women who received a diagnosis of BC completed a BC-specific HS questionnaire 1, 3, 6 and 12 months after surgery. ANCOVA for repeated measures and multiple regression analysis were used in the analyses.

Results

Women scoring high on trait anxiety had significant (P < .005) lower Body image, worse Future perspective and Sexual functioning, and more Side-effects than women who did not score high on trait anxiety. At 6 and 12 months after surgery, the same aspects of HS were predicted by higher trait anxiety scores.

Conclusions

Higher scores on trait anxiety resulted in worse scores on four HS domains, indicating that there should be more attention for this group of patients, even before treatment starts.

Breast self-examination in long-term breast cancer survivors

INTRODUCTION

For many breast cancer survivors, continued surveillance will be necessary to increase the possibility of finding a new diagnosis in an early stage. One such surveillance approach, breast self-examination, has not been studied specifically in breast cancer survivors. The current study was designed to assess the practice of BSE in a sample of long-term breast cancer survivors, and to examine the personal, emotional, cognitive, and health-care provider factors that may contribute to its performance.

METHODS

Three hundred forty-five breast cancer survivors (34% response rate, 345/1,001) diagnosed with in situ-stage II breast cancer between 1997-2004 at a community hospital provided answers to a mailed, self-report questionnaire.

RESULTS

Seventy-six percent of respondents reported that they had performed a BSE in the last 30-days. Forty percent reported performing BSE once/month, 39% more than once/month, and 21% less than once/month since their diagnosis. Most of the women (90%) reported that a doctor or nurse told them to perform a BSE once/month since their diagnosis, although only 69% had actually been shown how to perform a BSE. Consistently, the perception of increased barriers to BSE performance was associated with performance of BSE less than once/month (OR = 1.4, 95% CI 1.2, 1.6; OR = 0.8, 95% CI 0.8, 0.9). In addition, depending on the model, age (OR = 1.1, 95% CI 1.0, 1.2), perceived effectiveness of cancer treatments (OR = 0.7, 95% CI 0.5, 0.9), and perceived benefits of BSE (OR = 0.8, 95% CI 0.7, 0.9) also was associated with differences in BSE performance.

CONCLUSION

The current study suggests that breast cancer survivors between 4 and 11 years from diagnosis practice BSE, although their perception of the barriers to conducting BSE influences the frequency of this behavior. Further examination is needed to understand why some survivors perceive greater barriers to BSE performance than others. Also needed is a prospective examination of BSE performance using behavioral measures in relation to self-report.

IMPLICATIONS FOR CANCER SURVIVORS

Increased attention should be paid to this particular screening behavior performed by a majority of breast cancer survivors by both researchers and health-care providers alike. Whether survivors perform the behavior correctly and the impact it has on their emotional and cognitive well-being should be further explored.

Psychological factors related to delay in consultation for cancer symptoms

This research investigated psychological characteristics associated with delay in seeking help for symptoms of rectal cancer. Sixty nine subjects reconstructed pivotal events beginning with symptom onset and ending with medical consultation, and completed the Temperament and Character Inventory (TCI) and the State-Trait Anxiety Inventory (STAI). The mean delay time was around 6 months, with about 1 out of 6 subjects waiting one year or more. Subjects estimated the lengths of two sequential segments of total time to consultation: (1) Symptom Appraisal time (from symptom onset to recognition of possible seriousness), and (2) Action Appraisal time (from recognition of seriousness to medical consultation). Symptom Appraisal time accounted for over two-thirds of total time and was associated with low scores on the TCI Harm Avoidance scale (TCI-HA), indicating dispositional insensitivity to threat, and marginally associated with less education and younger age. Action Appraisal time was not associated with any demographic or psychological variables. Low TCI-HA scores were also associated with lower likelihood of previous cancer screening, and with better judgments of premorbid health. Low STAI Trait scores were associated with better judgments of premorbid health and fewer doctor visits. Results are discussed regarding the importance of understanding dispositional characteristics related to health behavior.

Predictors of cognitive appraisals following genetic testing for BRCA1 and BRCA2 mutations

The objectives of this study were (1) to describe perceptions of stress and confidence following genetic testing for BRCA1 and BRCA2 (BRCA1/2) mutations and (2) to identify predictors of these processes. Participants were 130 high-risk women affected with cancer who received BRCA1/2 test results. Individual difference characteristics and interpersonal factors were measured by self-report before genetic counseling and perceptions of stress and confidence were evaluated by self-report 1 month following disclosure of test results. BRCA1/2 test results had a significant effect only on perceptions of stress (beta = 0.38, p = 0.0001), while trait anxiety had a significant effect on both perceptions of stress (beta = 0.44, p = 0.0001) and confidence (beta = -0.41, p = 0.001). These results suggest that interventions designed to address perceptions of stress related to medical decision-making and familial concerns may need to be targeted to BRCA1/2 mutation carriers and individuals who are highly anxious.

Reassurance and the anxious cancer patient

Many cancer patients are anxious even when disease is in remission. Anxiety about health, ‘health anxiety’, has distinct features, notably seeking medical reassurance about symptoms. Doctors may then communicate that these symptoms are not due to serious illness, a process known as ‘reassurance’. However, reassurance may inadvertently perpetuate some patients' anxiety. We aimed to observe the relation between symptoms, anxiety and reassurance in consultations with cancer patients. A total of 95 outpatients, with breast or testicular cancers in remission, completed questionnaires measuring health anxiety at study entry, then general anxiety – before a consultation, immediately afterwards, 1 week later, and before their next consultation. We examined symptoms reported and reassurance by oncologists from audio recordings of consultations, and the outcome of subjects' anxiety. The results showed that substantial health anxiety was reported by one-third of the patients. Patients with higher levels of health anxiety reported more symptoms during consultations. Reassurance was ubiquitous, but not followed by an enduring improvement in anxiety. Certain forms of reassurance predicted increased anxiety over time, particularly for subjects who were most anxious. In conclusion, health anxiety can be a problem after cancer. Reassurance may not reduce patients' anxiety. Some reassurance was counterproductive for the most anxious patients. Oncologists may need to use reassurance as a procedure, balancing risk, and benefits, and patient selection and to manage cancer patients in remission.